Workability

There can sometimes be a delicate balance in therapy, between challenging people to try something new and step away from ways of coping that are easy because they’re habits, and at the same time respecting that people have different ways of doing things, different values and beliefs, and in the end have to choose what works for them.

In a recent discussion, someone asked me why Psychology is so quick to judge treatments and why ‘evidence’ is restricted to therapy that has been subject to things like randomized controlled trials and so on. After all, lots of people come to see this person after ‘conventional’ treatment has failed, and they feel very happy with the treatment he gives them.

To answer that question, and at the same time give due regard to individual choice, I am glad I have been introduced to the idea of ‘workability’. In the end, although I can provide lots of information about new strategies, it is up to the person I’m working with to choose what to do. This is both exciting and frustrating!

What is this thing called workability?
It’s the idea that one way to check in as to whether something a person is doing to manage their pain is actually helping is to ask whether this is helping them to live their life aligned to their personal values. Is it working?

Let me give you an example.
(note to readers: all clinical examples are drawn from people I have worked with, but details are changed, or the example could be an amalgam of several people, just to protect confidentiality.)
Jordan is a young man with fibromyalgia. His main problems are widespread pain, fatigue, and he has a long-standing cannabis use that he regards as pleasurable and isn’t keen on giving up. In terms of the problems he wanted help with, Jordan said he would like to return to work, he’d like to have better sleep, be able to set and stick to goals and he’d like to exercise regularly so he can feel more healthy and return to some of his previous sporting activities.

Jordan has been prescribed antidepressant medication because he can get quite low, and he’s also been attending massage and acupuncture from time to time. He says these two last treatments help, but he finds they are expensive and last for only a short time.

Some of the work we’ve done together has included getting a fitness plan organized, worked on activity management so his days are more structured and he doesn’t run out of energy before the end of the day. Both of these things are also intended to help with sleep management, because he has trouble getting off to sleep and remaining asleep, and wakes feeling unrefreshed in the morning.

Here is where I struck some resistance: Jordan isn’t keen on stopping his use of cannabis, and he has been using it both to relax and to help him get off to sleep! He has been a habitual cannabis smoker for about 15 years, and does meet criteria for cannabis dependence (ie he does experience some withdrawal symptoms when stopping it’s use).
I hasten to add that I do recognize there can be benefits from using cannabis, the relatively low risk in harmful effects by comparison to alcohol or tobacco, the positive effects on some types of chronic pain etc etc. It is illegal to possess cannabis in New Zealand, and there is insufficient data about the use of cannabis for managing chronic pain – but quite apart from this, in Jordan’s case, the cannabis is, I think, contributing to his sleep problem.

How? Well, part of getting to sleep is being able to slowly wind down and relax. We often wake throughout the night, usually only very briefly and most of us roll over and put ourselves back to sleep quite quickly. In fibromyalgia, sleep quality is poorer than for many people partly because of changes to the depth of sleep – stage 4 sleep, where we are the most deeply asleep, is disrupted in this condition and frequent waking is a feature.

In Jordan’s case, his usual routine is to get very stoned before he goes to bed, falling asleep as soon as he puts his head on the pillow. However, he wakes frequently during the night and has trouble getting back to sleep.

I put the idea to Jordan that maybe one reason he had trouble falling asleep in the middle of the night is that he has forgotten how to do this himself – his regular use of cannabis means he falls asleep, but it is the drug that is doing it, and not himself. When he wakes in the middle of the night, his initial biologically-driven need to have sleep is partially satisfied, and because he hasn’t been putting himself to sleep and has forgotten how to wind down himself, he can’t just roll over and allow himself to gradually drift off.

I pose this as a hypothesis, because I don’t know whether this is the case, and I won’t unless he carries out the experiment of not using cannabis for a while and learning how to fall asleep naturally. (Don’t worry, btw, I always include hinges like sleep restriction and sleep hygiene when we’re working on sleep problems!)

Well, Jordan has, after some reluctance, agreed to give it a go and stop smoking before bed so he can learn how to fall asleep himself. It is now a couple of months since he stopped and he says his sleep is a bit better in that he can fall asleep himself, and he is waking less often and when he does wake, he can fall asleep quite quickly.

But, and here is why I chose to use him as an example today, he doesn’t want to remain off the cannabis because he enjoys the buzz.

What to do?
I personally won’t voice an opinion on cannabis use with an individual. If someone is using it, and they recognize that it’s illegal, and want to take the risk, that’s their call. What I do have an opinion about is helping people decide for themselves whether this is going to help them do what is important in their life. Does it work in the bigger picture of life goals and valued activities and roles?

My question to Jordan is whether using cannabis is working for him. What are the good and not so good aspects of smoking?

It is his job to decide whether cannabis is helping him achieve what he wants in his life. It’s mine to help him look at the short term and long term consequences of using, and point this out to him. I have the responsibility of knowing the evidence on health and behavioral effects of it, he has the responsibility to judge whether this is important to him in terms of his goals.

I have the same response when it comes to other treatments, both hands-on such as acupuncture and massage, and psychological/self management – oh and medical interventions as well. Even if there is good evidence for an intervention, if it doesn’t help the person live according to his or her values, it’s not going to be good.

So, in answer to people who would suggest that I am biased against certain types of treatment, the answer is yes – I prefer to use the insights from research (which is, after all, the pooled experiences of many people under controlled conditions), but in the end the question to be asked is whether it is workable for the individual. I hope that I have the honesty to give people the opportunity to know both sides, and make a decision for themselves, rather than only giving one side of the evidence.

Hi Marianna
While research doesn’t necessarily hold true for individuals, it does hold true for ‘the majority’ – so I use it as a starting point with people. It’s then all about HOW it’s presented and acknowledging what is important to individuals (their values) and helping them work through the process of choosing one way or another. While individuals don’t need a study to tell them whether they feel better, what evidence does give us is unbiased information on what it might be that has helped them feel this way, and what parts of ‘feeling better’ is being directly influenced. This helps us refine the strategies and recommendations we make, and so help more people more effectively. What offends me is when people deny that science has a place in health care, and suggest that it’s all about what individuals say without recognising that each one of us can be well-mistaken about what has or hasn’t influenced our situation. Take the kid that thinks it is his or her fault that Mum and Dad are separating; or the sports person who wears his ‘lucky socks’; or the people who keep buying the same set of ‘lucky numbers’ on their lotto ticket, thinking that this gives them ‘a better chance’ of winning! Our wonderful brains take shortcuts that reduce the time it takes to come to conclusions, but make huge assumptions about what is and what isn’t. And the worst part of it? Even knowing that we have these cognitive biases doesn’t make us immune from their influence! If you don’t believe me: try these Psychological biases – try them for yourself!